The removal performance and mechanisms of diatrizoate (DTA), a typical iodinated contrast medium, from water by nano-sized zero-valent iron (nZVI) under aerobic conditions were investigated in this study. Reactive oxygen species (ROS) and transformation products were detected with electron spin resonance and liquid chromatography electrospray ionization tandem mass spectrometry, respectively. Furthermore, the effects of several operational parameters on DTA removal were illustrated. The results showed that nZVI had a much higher DTA removal ability compared to microscale zero-valent iron (mZVI) in the presence of oxygen. Moreover, the detection of ROS and I- as well as the analysis of intermediate products suggested a combination of oxidation and reduction pathways for DTA removal by nZVI under aerobic conditions. Additionally, a high dosage of nZVI and acidic conditions led to the enhancement of DTA removal, while nZVI aging, as well as chloride and nitrate ions in the solution, had negative effects on the degradation of DTA by nZVI in the presence of oxygen.